Transcript: Preparing for MACRA Part Three featuring Dr. Gary Loyd and Ann Marie Creed Welcome to part three of the three-part series collaboration between the American Hospital Association and the American Society of Anesthesiologists on preparing for MACRA. I'm Dr. Jay Bhatt, AHA's Chief Medical Officer and President of the Health Research & Educational Trust. I'm pleased to be joined by Dr. Gary Loyd, Anesthesiologist, and Ann Marie Creed, Vice President of Operations at Henry Ford Health System, for a discussion about the work they've done to get ready for MACRA. We really appreciate the leadership of Wright Lassiter, III, President and CEO at Henry Ford Health System on our board. The work that Henry Ford is doing in this area is really a great example of what is possible as we try to meet the challenges of a dynamic healthcare system environment. Gary and Ann Marie, I'm going to pose a few questions that we can have a conversation about. Let's start with, what are some of the initial challenges you've faced in getting your system MACRA ready? I think the biggest challenge to start off with is educating everybody that there's a problem and that it's coming, and that we already have a problem and we're not aware of it. Really understanding that we can do better. There are paradigm changes out there that other people have tried and it worked. It's something that we need to take on here. So, there's a large amount of education and discussion that has to occur to move a large institution like ours in a different direction. I would definitely echo Dr. Loyd's comments on that. Again, with a large medical group, it really has been a challenge to move them from the status quo to, again, kind of think outside the box and look at what other initiatives are out there that can change patient care that haven't already been tried before. When we think about these challenges that you both were just articulating, are there some examples you can share about how those challenges were overcome? From the Perioperative Surgical Home Initiative, I spent probably 80% of my first three months just talking to groups. I had implemented the system at a previous institution, so I had some background. I had some knowledge. If I was having to start this from scratch, I would bring in some expertise. I would send some people out to places where this is going. The Perioperative Surgical Home Learning Collaborative has a lot of good resources and educate people about it. When you're creating a large paradigm change, people absorb only so much. You have to come back... I mean, keep the conversation going so that people can get together. In our Perioperative Surgical Home now we have 169 volunteers. They range from surgeons to anesthesia, to nurses, physical therapists, nutritionists, environmental services. Everybody has a voice, everybody that's caring for the patient, and we all participate together to
improve the entire system. It's a paradigm change. It really is. But you've got to do the conversations to get through the challenges. Absolutely. Thank you. I think you're right about this. It's socializing it, learning from those conversations, taking that learning, and adapting and continuing to build on that, so that there's really a cadence of communication and learning that leads to stronger partnership and awareness about how to be successful in the changing environment of payment. Ann Marie, you were going to make a comment? So, I was going to make a comment, also, on that communication and that vocalization by individuals, also helps institutions understand where do they have partners? So, that, I think is also one of the challenges, and really trying to figure out which areas, which groups, which disciplines are more ready to make change. And so, those really are where you want to focus on as well. Because those really help to create your early wins in moving things forward. And if you can do some of those, and get some of those partners really early on, that really does help to move the initiative. You're right. When you have these conversations, it can spark perspective and thinking that allow you to see what partnerships might be readily available and what work needs to be done to get to a state of readiness for positive outcome. So, building on some of that conversation, what guidance would you give individuals are you are struggling to prepare for MACRA? Certainly, have the conversation, but in addition to that? Yeah, I'll let Ann Marie go first this time. So, one of the things that I think as far as getting ready, is to not think about taking on too much. And we kind of touched on that a little bit, but not taking on too much all at one time. You really have to peel the parts in, and I think that's Dr. Loyd's favorite acronym, is peel apart that onion and really look at what can you really work on? Again, what are those early wins? What are the things that you can hit home with versus... There's no way that you can tackle everything, and so really, it is important to try to figure out how much can you take on? Take on those smaller pieces, and to do it in bits and pieces rather than try to take a whole, big chunk because many individuals only really start to focus on that larger chunk and then they get very anxious and very overwhelmed, and so again, you have to be able to peel things apart for them to really show them how doing smaller pieces really will impact the whole better. Yeah, I totally agree with Ann Marie has to say, but I think the big, big key to this is having the entire C-Suite on board. With this initiative, and not just lip-service, but they also invested some resources, learned themselves, and have been supportive of pushing this forward, and Ann Marie herself is a great example of a C-Suite type person who can really make things happen, and I just really value all the people from administration who are actively participating in all these. They are active partners. So, I mentioned the whole cast of people and I didn't
mention one administrator, and yet they're probably as important as anybody on that team, so I really have to underline, if you're struggling, first, get your administration piece on board, and be willing to share. Make yourself vulnerable. We have institutions where the medical group or sets of physicians are not at all integrate with the institution and so they have a problem with the communication and willingness to share information. Well, you have to build that trust and go in to the basics of how do you build the trust, and putting to together piece by piece until you get to the point where you can actually mutually share information. It goes back and forth, so that you can make the progress you need to make. So I think those are wonderful insights on how folks can overcome some of those struggles as they're moving down the journey of MACRA. One of the things that's interesting about this conversation is that it's clinician/administrative leadership working together to advance these issues, and support the hospital and health system team to advance work on MACRA. Can you talk a little bit about how working together has impacted members of the care team and what is it about some of the ways that you've worked together in a dyad and with other members of the Henry Ford Team that has helped you move forward some of these actions related to MACRA and generate the results that you spoke about earlier? Well, I've seen a lot of benefits, especially when we started with the Lean process for OR turnover time. Both the physician leadership and the administration allowed the people that were actively doing the work to have an active voice in what was being designed, what was being talked about, so that it wasn't top heavy. It was actually ground-up, with very much support from both physician and administration. I think that was has happened and the benefits of not only the conversation, but getting results, because as everybody starts to understand and work together, their job gets easier. Because you're tearing down barriers. And word is getting out very quickly about the progress. I've got five service lines who are begging to join us so they can do it, but we don't have the resources lined up yet to take them on, though they are on a timeline and they will be added in an appropriate time, and that's all by word of mouth of the success. It's only been a few barriers that have been, but it's enough to be substantial enough that other people want to do it, too. And so, provider happiness and patient happiness, a lot of these things are being created around the country and they think they're being patient-centered because they're doing it for the benefit of the patients, but until you actually bring in the patient into the discussion as well, you don't get that perspective and you don't understand how what you're doing is impacting the patient. You say, well, we're all patients. Yeah, we're all biased patients, because we all have healthcare experience. When we bring in our actual patients who don't have that healthcare experience, we gain a bigger understanding.
The patient advisors get an orientation, and during their orientation, most of it is spent in how do you navigate the healthcare system? They have no idea how hospitals and healthcare systems are put together. They see it from their vantage point, but there's a lot of things that we, as healthcare providers take for granted and they don't know it. And so, when we learn what they need to know, then it makes our decision-making and how we're putting it together a little better. Just like while I was talking about the room turnover time and we hit the plateau, and patients wanting to go to the bathroom and see other family members and so forth, and that was causing us not to be able to reach our mark. We had to slow down, because we were not willing to put patient satisfaction and what they want at risk. We had to listen to what they had to say and be creative in our redesign, so we are using the patients to help us tell everyone how to make it better. Yeah, I agree with Dr. Loyd. Having those patient advisors is important, no matter what's your topic anymore, because again, you don't really understand it from the patient's perspective until you really ask them. We assume we know what the patient wants or what is important to the patient in that, but we don't tend to necessarily ask them. So I totally agree with Dr. Loyd in that that is an important part, as well as that interdisciplinary, interprofessional group that he talked about as well. Again, making sure everybody is at the table and making sure that everyone is willing to listen to each other, because, again, you don't necessarily understand how another piece from another department or area really interacts with yours. Again, I think it's also very important to be open and that's another success I think that Henry Ford has had, is we've been able to get those individuals to the table and are very open with listening to what the struggles are for different areas and trying to help resolve them as a group rather than assuming that we know, and/or dictating what we think should be done. Absolutely. I think, when we talk about having the right conversations, a number of them, we have to think about that as well, with patients and families. Often, we're seeing in some places around the country, the Patient and Family Advisory Councils are starting to play a role in helping provide education and awareness, and input on to designing the right kind of approach to support that healthcare system change and certainly related to MACRA. Now, one of the questions I was interested in your perspective, Gary and Ann Marie, was what were you surprised by in getting your system MACRA-ready? And were there some particular lessons, "ah-hahs", things you didn't expect that then were really important to be able to understand to move towards the success that you all have experienced? My biggest surprise has been how deep we have to go into detail to actually get to the root-causes for the problems that are going on and actually do root-cause
analysis. We just did a root-cause analysis of why aren't we being as compliant as we want to be with our glycemic control? And just something that you would think is like, "Okay, you measure the glucose, and you give the insulin. What's the problem with that?" Well, we found out that there were 14 actual barriers that kept people being totally compliant all the time with that glycemic control and so we're having to revamp the entire policy and protocol, how we're putting things together to take care of those barriers which we can't change, and then there's other barriers which we are changing, because of that. But you really have to be willing to get down into lots of detail. And this is where the data is really going to be helpful. But also, just keep working at it and use your Six Sigma and Lean Processes to get down to the point where you can make a change, but it surprised me how far down you actually have to go and so it doesn't run as fast as you think it's going to run. It's going to take time when you get down to all those details. I agree. Some of the "ah-hahs" are when you really start to look at those processes, you really do come to realize some of the things that have been out there for years or decades, as far as part of the process itself and then there's this "ah-hah" as far as, "Oh, that's why we do this." And so there's also been the pushback, "Okay, let's really re-look at what is the value of that?" So there's always those "ah-hahs" when you really start to delve into these various processes. And again, it's just historical. It may be just expected from staff that we've always... The comments. We've always done it this way, type of thing. So, those are the things that always are somewhat of a barrier to overcome, is to get them to understand, "Okay what's the value of it? Why are we doing this?" Thanks for those comments. One of the other key items that's related to what we just talked about is part of what is helpful in getting a system MACRA-ready is having the right people around the table. And so, from your perspective, and through your experience, who do you think should be represented in your MACRA-readiness team? So, for the MACRA-readiness team, again, we talked to that. It really does need to be interprofessional team, and so again, your clinicians and all types of clinicians. Again, physicians, depending on what piece you're really looking at. So, clinicians, maybe APPs, nursing, of course, and then as well, having pharmacy, having lab, having supply-chain. So, again, it's not just your clinical groups that need to be at the table. You need to have those other groups as well. I think that that's very important, as well as we've already talked about from administrative, as well as potentially patient advisors. Yeah. I have to underline that. It really needs to be interprofessional, interdisciplinary. On one of our service lines, our biggest cheerleader and person who has had the greatest impact has been the dietician. So, you don't know exactly where your biggest gains are going to come from. There's lots of talent in your own institution. So, you have pull them all together. We're continually doing education where people are still learning about systems and
learning about how to do Lean and how to do Six Sigma. It's just not been part of anybody's past education. We bring expertise in to lead us, and to facilitate, but it's still a process and I would look at, talk to everybody else who is doing this, and learn how to do it yourself. Excellent. Well, Gary and Ann Marie, thank you so much for your contributions and perspectives on this topic. It's clear that you all thought quite a bit about this and have put a structured, systematic approach together to address it, and are continuing to learn along the way. I think through the conversations and podcast one and podcast two, and now in podcast three, great pearls of wisdom, really based on personal experience that I think we can all learn from as we're moving forward in this time of macro-economics, holy mackerel, and any other terms that come along with MACRA. So, thanks so much for all that you're doing, and we look forward to our continued work together with the American Society of Anesthesiologists and Henry Ford Health System. Thank you. Yes, thank you. Appreciate it.